Continuity of care

Dear Colleagues,

Obstetric care, including intrapartum care, was a big part of my clinical practice. Besides the unique experience of welcoming new lives into the world, I really enjoyed getting to know expectant mothers and their partners at this special time of life and, subsequently, continuing to be part of their life and that of their family for matters pertaining to their health and health care. To my learner colleagues, I empathize with the fact that it is hard to get a feel for family practice with short, defined rotations, because much of the fun of family practice lies in relational continuity. Longitudinal, integrated clinical experiences are more appropriate to better appreciate this critical element of family practice, and the expansion of longitudinal integrated clerkships is promising.

The evidence regarding the importance of continuity of care is robust. Relational continuity with a family doctor, nurse practitioner, or primary care team is associated with reduced visits to the emergency department and lower hospitalizations and rehospitalizations in patients with chronic conditions^1,2 and in the general population.³ Investments in continuity of care are also reflected in reduced health system costs and improved efficiency.^4,5 Continuity enhances patient safety, as well as both patient and provider experiences with care.^6-8 It checks off all the boxes of the quadruple aim.⁹

The acceleration of virtual care through the pandemic, combined with ongoing issues related to access to care, including changing societal expectations regarding access, has stimulated the expansion of private for-profit entities. Access to a provider 24 hours a day, 7 days a week is facilitated, for a fee. Access is privileged with the risk, on a large scale, of health care becoming more transactional in nature, with no continuity and the potential duplication of services if physical examinations or investigations are required, to say nothing of concerns regarding patient safety.

As much as the commercialization of health care is of concern, we need to recognize that 4.5 million to 5 million Canadians do not have access to a regular health care provider.¹⁰ Before the pandemic, there was a slight upward trend in the percentage of patients attached to a health care provider.¹⁰ We know that access to care for marginalized populations remains a considerable issue. I suggest that we need a deliberate strategy to accelerate access and attachment to a family doctor, nurse practitioner, or primary care team. Our defence of Canada’s publicly funded health care system must include a willingness to learn from innovation that shows promise in improving access and in supporting continuity. In an environment in which patients have a growing variety of options to access care, it is crucial to adapt to the evolving technologies (eg, video call, secure messaging) and expectations. The Patient’s Medical Home (patientsmedicalhome.ca) model of care is our vision for better care in family practice, at the right time, by the right provider, including virtual care where appropriate.¹¹ It needs to be contextualized and remains a solid foundation to build upon. Governments need to support the infrastructure necessary to enhance both continuity and access, and providers and patients need to be involved in co-creating solutions to strengthen publicly funded, community-based care.

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